A coming revolution walks a fine line

The Chronicle of Higher Education has an excellent in-depth article on the most likely candidate for a revolution in mental health research: the National Institute of Mental Health’s RDoC or Research Domain Criteria project.

The article is probably the best description of the project this side of the scientific literature and considering that the RDoC is likely to fundamentally change how mental illness is understood, and eventually, treated, it is essential reading.

It is also interesting for the fact that the leaders of the RDoC project continue to hammer the reputation of the long-standing psychiatric diagnosis manual – the DSM.

First though, it’s worth knowing a little about what the RDoC actually is. Essentially, it’s a catalogue of well-defined neural circuits that are associated with specific cognitive functions or emotional responses.

If you look at the RDoC matrix you can see how everything has been divided. For example, stress regulation is associated with the raphe nuclei circuits and serotonin system.

The idea is that mental illnesses would be better understood as dysfunctions in various of these core components of behaviour rather than the traditional collections of symptoms that have been rather haphazardly formed into diagnoses.

Conceptually, it’s like a sort of neuropsychological Lego that should allow researchers to focus on agreed components of the brain and see how they map on to genes, behaviour, experience and so on.

It’s meant to be updated over time so ‘bricks’ can be modified or added as they become confirmed. An advantage is that is may allow a more accessible structure to understanding the brain for those not trained in neuroscience but there is a danger that it will over-simplify the components of experience and behaviour in some people’s minds (and, of course, research).

The RDoC has been around for several years but it recently hit the headlines when NIMH director Thomas Insel wrote a blog post promoting it two weeks before the launch of the American Psychiatric Association’s diagnostic manual, the DSM-5, saying that the DSM ‘lacks validity’ and that “patients with mental disorders deserve better”.

After a media storm, Insel wrote another piece jointly with the president of the American Psychiatric Association that involved some furious backpeddling where the DSM was described as a “key resource for delivering the best available care” and “complementary” to the RDoC approach.

But in the Chronicle article, head of the RDoC project, Bruce Cuthbert, makes no bones about the DSM’s faults:

“If you think about it the way I think about it, actually the DSM is sloppy in both counts. There’s no particular biological test in it, but the psychology is also very weak psychology. It’s folk psychology without any quantification involved.”

The DSM will not, of course, suddenly disappear. “As flawed as the DSM is, we have no substitute for the clinical realm for insurance reimbursement,” ex-NIMH Director Steven Hyman says in the article.

It’s worth noting that this is not actually true. In the US, diagnosis is usually made according to DSM definitions but insurance reimbursement is charged by codes from the ICD-10 – the free diagnostic manual from the World Health Organisation.

But the fact that the most senior psychiatric researchers in the US are now openly and persistently highlighting that the DSM is not fit for the purpose of advancing science and psychiatric treatment is a damning condemnation of the manual – no matter how they try and sugar-coat it.

The fact is, the NIMH have to walk a fine line. They need to both condemn the DSM for being a mess while trying not to shatter confidence in a system used to treat millions of patients every year.

15 Comments

So, our options are the DSM or this new method that reduces all mental states to physiological processes? Seems like going from the frying pan to the fire. I can’t see how the RDoC is going to do much other than create a further dependence on pharmaceuticals. Next thing you know we’ll have neuroscientists trying to tell us they’ve solved morality. I’m sure they’ll be a pill for that one day, too.

The RDoC is an interesting idea and I hope that it eventually proves to be useful. However, it is the codification of reductionism. Most of the domains focus on biological level processes and it appears to me that the field of mental health as viewed by NIMH is to become one of applied neuroscience. This is problematic because it ignores the wide body of research which demonstrates the contributions of psychological and cultural perspectives to mental health and assessment of dysfunction. The DSM has major issues, of that there is no doubt, but “starting fresh” by replacing psychology with neuroscience seems to be a well intentioned by poorly aimed endeavor.

Neither ICD-10 nor DSM serve very well for the purpose they’re made for. This is largely due to a basic lack of comprehension at the time of inception of how the human mind is a mere accidental artifact rather then an evolutionary result.
Once this has been taken into account you can start from scratch and this time with a whole lot less hubris and a lot more common sense.

Not exactly true, that ICD-10 nor DSM serve their purposes well. There is plenty of room for improvement on the validity and probably the effectiveness aspect, but that doesn’t imply little or no validity/effectiveness. And they are certainly of high utility for:

(1) providing a standard frame of reference endorsed by most clinicians, enabling them to achieve better diagnostic agreement and improve communication, including statistical reporting on psychiatric morbidity, services, treatments, and outcomes.

(2) More precise diagnostic criteria and instruments have become the norm in research. Although most research diagnostic criteria are still provisional, they can be refined or rejected by using empirical evidence.

(3) Teaching is now based on an international reference system that provides a worldwide common language.

(4) And public access to the diagnostic criteria used by mental health professionals has helped improve communication with the users of services, caregivers, and society at large.

The points above were pulled from this deep, incredibly thorough and even-handed discussion on this topic, definitely worth a read for those interested:

I assumed it goes without saying that a basically faulty system doesn’t improve by tinkering with it. It’s like AGW, once you assume A to be true, nothing you can change that will improve the disconnection between reality and theory.

The diagnostic models are faulty because they assume the human consciousness (‘the mind’) to be a collective result of evolution. That our consciousness is a progressive improvement on earlier primates.

Which it isn’t. It is (in evolutionary terms) an unfavorable side effect of a too complex information processing system.

As such it will either go extinct (most likely) or consciousness evolves to be a entity on itself rather then a sidekick of a primate brain, enhancing its destructive tendencies.

The latter presumes that consciousness can become an entity on itself, which to my mind is rather unlikely because there is no evolutionary advantage in a pure rational being.

Any pure rational being would quickly decide that existence without purpose is pointless and stop to exist. Why bother.

You said: “I assumed it goes without saying that a basically faulty system doesn’t improve by tinkering with it.”

Basically faulty? Where do you get that? Your solution is to…what? Just abandon all of psychiatry/psychology? You have a new system to replace it, or just ready to call it quits altogether?

You also claim: “The diagnostic models are faulty because they assume the human consciousness (‘the mind’) to be a collective result of evolution. That our consciousness is a progressive improvement on earlier primates.”

The diagnostic models make no such assumption. In any case, consciousness is almost certainly a result of evolution, but that does not necessarily imply some sort of “improvement,” that’s a value judgment no one but yourself is claiming, and a misunderstanding of evolution (there is strictly no ‘progression’ or ‘improvement’, just change).

You said “consciousness is an unfavorable side effect of a too complex information processing system.”

Interesting theory. Any actual evidence in support of that? I assume you’ve empirically defined consciousness and also complexity for such an assertion as well?

Then you say “As such it will either go extinct (most likely) or consciousness evolves to be a entity on itself rather then a sidekick of a primate brain, enhancing its destructive tendencies.”

Huh?

“The latter presumes that consciousness can become an entity on itself, which to my mind is rather unlikely because there is no evolutionary advantage in a pure rational being.”

Huh?

“Any pure rational being would quickly decide that existence without purpose is pointless and stop to exist. Why bother.”

Huh? Any of this actually have to do with your (unsupported) claim that diagnostic manuals don’t serve the purposes they are designed for?

Yeah. The answer i expected. You are trained, your mind is closed. You’re forced to think along the same lines. Maybe others are more open minded. Who knows. Who cares. Nothing you are going to do nor anyone else will influence the ultimate outcome the least bit. Hubris is a human condition, but among scientists it is usually more intense.

Indeed so. Snarky comments display either a total lack of understanding with a need to compensate by trying to denigrate the other or just a nasty personality that feels attacked. Huh? Huh? Huh? isn’t an argument, it’s trying to escape argumentation by ridiculing.
It’s infantile and renders your post meaningless. So why post it?

insel also says DSM should remain the diagnostics tool it is, for now. At this stage RDoC is in essence a set of guidelines for clinical research and people will need to follow this to get NIH money. I am looking forward to see how it will evolve and influence both animal and clinical research.

Great article, nice and balanced. There should be room for multiple opinions and strategies, and I think you hit nicely on the evolving dichotomy.

It is my opinion that the inception of RDoc is a reflection of our nation’s entry into the Neuroeconomy. Just as the NFL Concussion controversy shows our shift of valuation from horsepower to cognitive power, the shift from the Intuitive DSM classification to a neurobiological scheme reveals the premium we are placing on proper brain function.

And as a Neuroscientist, it shouldn’t be surprising that I would disagree with Todd’s comments. I am personally excited over the prospect of objectively tracking the impact of mindfulness meditation on neuronal structural integrity. And as long as patients are going to be using medications, why not develop a template for higher precision, reducing the potential for side effects?

Ultimately, we probably can expect another level of insight to derive out of further research. I would predict that ten years from now, when we are on the path to incorporating prostheses which extend our access to the Exocortex, our discussion about NeuroOptimization will be entirely different.

Until psychology/psychiatry can make clear, delineated diagnoses based on objective data like biomarkers, brain structure/function, etc., then we are stuck clustering ‘disorders’ mainly by self-reported symptoms. This is not necessarily a bad thing:

but obviously isn’t optimal either, and leaves considerable room for improvement…we are essentially stuck where medicine was 100-200 years ago (describing/clustering by symptomology). I am holding out some hope for RDoC, but as some commenters already observed, it seems to be several layers down of reductionism when we haven’t even cracked the top layer yet.